NURSING AUDIT Introduction: Nursing Audit is an evaluation of nursing service. It was introduced by Industrial concern.

The report of nursing audit of the hospital, published in 1955, related to the planning, delivery and evaluation of care. It determines its effectiveness, and any area needing improvement and whether the planned care was given. Definition: Audit is a systematic examination of books and records of business or other organization in order to ascertain or verify and report upon the fact regarding the financial operation. Nursing Audit refers to assessment of the quality of clinical Nursing. Purpose: Evaluating Nursing care given Achieves deserved quality of nursing care Stimulates to better health. Contribute to research Focuses on care provides. History of Nursing Audit: Nursing Audit is an evaluation of Nursing service before 1995, very little was known about the concept. It was introduced by the industrial concern and the year was the beginning of medical Audit. Concept of Nursing Audit: A Nursing audit is a through investigation made to evaluate the overall nursing care received by a patient. An audit is generally done by experienced nurses and audit committee who do not actually work in the ward where the audit is being carried out. 1

The concept of nursing audit is based on debit and credit system. Debit system: Death of the patient which have been prevented. Complication of disease due to neglect of nursing care. Left against medical advice. Hospital born infection. Error in treatment Absence of total patient care Lack of application of nursing process. Nursing care learners. Credit system: Number of recovered patient. Expansion of health knowledge in patients population. Short stay in the hospital Regular follow-up in the community Research or problem oriented care approach Measures for improving public image Good nurses record Debit system is negative in nature. Its emphases on illness where as credit system is positive in nature and it emphases on health. Objectives: To justify the cost increased on human and material resources. To study the quality of patient care against defined criteria. To take remedial action towards cost effectiveness. To assess the competence of nursing staff and serve to keep up to date knowledge and prevent repeated mistakes. GUIDELINE FOR NURSING AUDIT: Objective or Aim: Involvement of the health care and fact-finding mission. 2

Standards: Should be set by participating clinicians. Control: Should be by participating clinicians and by voluntary participation. Method: Should be no threatening interesting objective and repeatable. Records: Should have adequate clinical materials. Types of Audit: There are two types1. Internal Audit. 2. External Audit. 1. Internal Audit: It is carried out continuously by hospital staff and which consists of process of separating and classifying clinical records and evaluating the nursing care given. 2. External Audit: An outside agency periodically tests the completeness and accuracy of internal audit. Methods of Nursing Audit There are two methods; 1. Retrospectives view: This refers to an in depth assessment of the quality after the patient has been discharged, and patient chart is the sources of data. 2. Concurrent view: This refers to the evaluation conducted on behalf of the patients who are still underlying care. It includes assessing the patient at the bedside in relation to predetermined criteria, interviewing the staff responsible for his care and reviewing the patient records and care plan.

Audit committee: Before carrying out an audit, on audit committee should be found. Comprising of a minimum of five members, who are interested in quality assurance, are clinically competent and able to work together in a group. It is recommended that each member should review not more than 10 patients each month and that the auditor should have the ability to carry out an audit in about 15 minutes. If there are less than 50 discharges per month, then all the records may be audited. If there are large numbers of records to be audited, then an auditor may select 10% discharge. Nursing Auditor: The choice of nursing auditors depends upon whether the type of nursing audit to be under taken is internal and external accordingly. 1. Internal auditors: The nursing experts from within the hospital are deputed for internal audit and the auditing is done within agency or hospital. 2. External auditors: The nursing and medical administration from the ministry, other agency or professional association like TNAI undertake the nursing audit in desired agency of a hospital.

Audit Cycle Set Standard

Implementing change

observe practice

Compare with standard Advantages: Can be used as a method of measurement in all areas of nursing. Scoring system is fairly simple Results easily understand Assess the work of all those involved in recording care May be useful tool as a part of a quality assurance programme in areas where accurate records of care are kept. Disadvantages: Appraises the outcomes of the nursing process. So, it is not useful in areas where the nursing process has not been implemented Many of the components overlap making analysis difficult. It is time consuming. Requires a team of trained auditors Deals with a large amount of information. Only evaluate record keeping. It only serves to improve

documentation not nursing care. 5

PROFESSIONAL STANDARD: Introduction: The nursing profession exists to meet the health needs of the people, offer services, which are vital to human and social welfare. It provides quality of care with desired outcome. Certain governing bodies set standard, what it is should be and control its function. Definition: A problem is an occupation with ethical components that is devoted to the promotion of human and social welfare. Nursing: Nursing is a unique function of the nurse to assist the individual sick or well in the performance of those activities, contribution to health or its recovery that he would perform unaided if he had necessary strength, will or knowledge and to do this in such a way to help him again independent quality as possible. Standard: Standard is a established rules or basis of comparison in measuring or judging capacity quantify contest and value of objects in the same category. Nursing standard: It is descriptive statement of desired quality against which to evaluate nursing care. Purpose of standard: Give direction and provide guidelines for performance of nursing staff. Provide a base for evaluating quality of nursing care, ranging from excellent care of usage care. Help to improve quality of nursing care increases effectiveness of care and improves efficiency. Help to improve documentation and record of care. 6

 Help to determine the degree to which standards of nursing care maintained and take necessary corrective action in time. Help supervisor to guide nursing staff to improve performance. Help to improve basis for decision making and desire alternative system for delivering nursing care. Justify demands or resource association. Helps to clarify nurses area of accountability. Help nurses to define clearly different level of care. Characteristics of standards: Statement must be broad enough to apply to a wide variety of setting. Must be realistic, acceptable and attainable Standards of nursing care must be developed by member of nursing profession. Should be phased in positive terms and indicated, acceptable performance that in good excellent etc. It must express what is desirable It must be understandable and stated in unambiguous terms. It is based on current knowledge on scientific practice. It must be reviewed and revised periodically Sources: The standard can be established, developed, reviewed or enforced by variety of sources as follows. Professional organization eg.TNAI Licensing bodies eg-INC, MCI & DCI etc. Institution / health care agencies eg. University Hospital, Health centers. Department of institution eg. Department of nursing Patient care unit eg. Specific patient unit Government unit at national, state local units. 7

 Individual eg.personal standard.

Classification of standard

Empirical Normatic End Standard

Types of standard

Means Standard

Outcome standard Process standard

Structure standard

1. Normatic standard: Normatic standard describes practice considered good or ideal by some authoretive group, professional organization formulate normative standard. 2. Empirical standard:

Describes practice actually observed in large number of patient care setting. It is formulated by regulatory bodies like INC, MCI 3. End and means standard: The end standards are patient oriented; they describe the change as desired in a patient physical status or behaviors. 4. Means standards The means standards are nursing oriented. They describe the activities and behaviors designed to achieve the end standard. It includes the information about nurses performances. 5. Structure standard: A structure standard involves the set up of institution the philosophy goals, objective and structure of the organization, facilities, equipments and qualification of employees the recommended relationship between the nursing department and other department in a health agency. 6. Process standard: Process standard describes the behavior of the nurse at desired care of performance a process standard involves of performance a process standard involves the activities concerned with delivering patient care. This focuses on what was planned, what was done and what was communicated and recorded. 7. Outcome standard: Descriptive statements of desired patient care result are outcome standard. An outcome standard measure change in patient health status. The change may be due to nursing care, medical care or as a result of variety of service offered to the patient. Structural standards are agency or group oriented process standard are nurses oriented and outcome standards are patient oriented. Standard and practice developed by international council of Nurses, 1949:

The Indian nursing council act is the only national legislation directly related to nursing practice. The right to refuse to treat a patient except in an emergency situation. The right to issue for fees The right to add a little or description to ones name Unregistered practioners are not allowed to hold position or appointments in public and local hospitals. Fundamental duties: To exercise a reasonable degree of skill and knowledge in treating patient. Owns a relationship to a patient has been established, there is an obligation to attend the patient as long as necessary. A practitioner must give personal attention to his case and answer calls with reasonable promptness Children must be protected from harming themselves. Special precaution must be taken in case of adults who are incapable taking care of themselves. The Indian penal code demands that poisonous drugs to be kept in separate containers, properly labeled and marked. There is a duty of secrecy to the patients. Dangerous diseases must be reported Nurses are considered solely responsible for their own professional act irrespective of their employing authority. Standard by the INC: The INC has approved a framework for the endorsement of practice standards. It has been developed in response to increasing requests from professional groups and other organizations for endorsement of their standards by nursing council.

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1. The council has in the framework for post-registration nursing practice education (May 2001) provided the framework on which particular competencies for a defined specifically area or a scope pf practice can be developed and demonstrated. 2. The scope of the specially or standards of nursing is defined as specially nursing practice is the exercise of higher. Levels of nursing judgment, discretion and decision making in an area of practice with a specific focus and body of knowledge and practice. 3. Practice standards, that have the purpose of improving the quality of professional services and recognize nurse in specialty or advanced practice, must be developed by current experts. Standards must be evidence based. 4. The standards allow for audit / monitoring. Individuals or groups of nurses must be able to use the standards to evaluate their practice. The standards could be used in a situation of evaluation or monitoring of professional competence by the disciplinary body. 5. The Indian nursing council Act is the only national legislation directly related to nursing practice. It provides a basis from which rules for nursing practice can be developed.a) The right to refuse to treat a patient, except in an emergency situation. b) The right to sue for fees. (Applicable only to private duty nurses or private practioners; other nurses are salaried) c) Unregistered practioners are not allowed to hold positions or appointments in public and local hospitals. d) There is a duty of secrecy to the patients. Records must be treated as confidential unless the practioner is called upon to give evidence in court. e) Dangerous diseases must be reported. f) Nursed are considered solely responsible for their own professional acts irrespective of the employing authority. Standard by the TNC:

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The state government controls nursing practice through the state nurses registration Acts. The state nurses registration councils have authority to prescribe rules of conduct, to take disciplinary action and to maintain registers of nurses, midwives and others. The TNC have acts that prevent registration or justify removal from the register for the following offenses 1. Conviction for a non-bailable offense. 2. Being found guilty of conduct indicating that the individual is not fit to be registered. 3. Possessing defects in character. Unethical practices prohibited the TNC are 1. The dishonest use of certificates 2. Procuring registration by false means. 3. Falsification of the register 4. Representation of the registration by an unrecognized person. 5. Representation of registration as a medical practioner. 6. A fine is the usual penalty imposed for disobeying the law stated by TNC. Legal standards of practice: Legal standards of practice nursing in a safe, efficient, competent manner, you must understand both the legal regulation of nursing practice and voluntary professional regulation of nursing practice. There are several types of laws that direct nursing practice. 1. Nurse practice Acts: In all status in the united states, nurse practice Acts regulate the licensure and practice of nursing, each state or province defines for itself the scope of nursing practice, but most have similar practice acts. The definition of nursing practice published by the ANA is in some ways representative of the scope of nursing practice as defined in most states. 12

In the last decade, how ever, many states have revised their nurse practice acts to reflect nursing growing autonomy and the expanded roles of nurses in practice. 2. Licensure and Certification : Licensure: In the United States, RN candidates must pass the NCLEX-RN, which is administered by the individual state boards of nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States. This provides a standardized minimum knowledge base for the client population nurse serve. Certification: Beyond the NCLEX-RN, the nurse may choose to work toward certification in a specific area of nursing practice. Minimum practice requirements are set, based on the certification the nurse is seeking. 3. Occupational safety and health Act: The occupational safety and health Act of 1970, known as OSHA, established legal standards that define safe helpful working conditions. OSHA is periodically updated and expanded, and it affects you as a nurse in two ways a) First, it sets standards for your working conditions. b) Second, some of the requirements of the law dictate how you manage clients. 4. Controlled substance Acts: Several laws have been enacted that address standards for drug development and marketing. These laws affect the process by which new drugs become available to clients. Most significant for you is the comprehensive drug abuse prevention and control Act of 1970. this law was enacted to regulate the distribution and use of drugs with the potential for abuse. 13

5. Health care quality improvement Act: One of the difficult issues in attempting to protect the public from unsafe and incompetent health care providers has been the tracking of information related to adverse licensure actions, malpractice payments and adverse professional actions.

6. Americans with disabilities Act: The ADA, passed in 1990, was enacted to protect persons with disabilities from discrimination in such areas as housing, employment, education and health services. The act uses a broad definition of disability that includes persons with AIDS or infected with the human immunodeficiency virus (HIV) and persons recovering from drugs or alcohol addition. Many of year clients may be disabled. As a result, you may be assisting your clients to assert their rights under this law, particularly if you work in an out patient or community health setting. JCAHO standard of Nursing Practice: a. JCAHO standard of case management: 1. In 1975 the JCAHO urged the use of outcome criteria to evaluate nursing. 2. Today the JCAHO continuous to recommend the use of Outcome criteria using a collaborative approach to patientfocused care. 3. This collaborative effort by the interdisciplinary work group begins before admission and continuous until discharge. b. JCAHO standards for quality improvement:

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The JCAHO (1996) is an external review board that establish standards for institutions to ensure that the institution functions within specifies guidelines. The hospital standards for nursing care are applicable to all clients in every setting where nursing care is provided. Recent changes in the JCAHO guidelines require the continuous monitoring and evaluation of the quality of nursing care provided by the department of nursing. c. JCAHO standards for client education According to the JCAHO (2003), the goal of client and family education is to promote healthy behavior and encourage the clients involvement both in the delivery of health care and in health care decisions, to improve outcomes. Educational efforts must take into consideration the clients psychosocial, spiritual and cultural values, as well as his or he desire to actively participate in the educational process d. JCAHO standard for medical mistakes: In January 2003 the JCAHO established National Patient Safety goals in an effort to reduce the risk of medical errors. These evidence-based recommendations require health care facilities to focus their attention on a series of specific actions. Data on the achievement of the goals will be made public each year. New goals are announced each year in July. The national patient safety goals for 2004 include Improving the accuracy of patient identification Improving the effectiveness of communication among care givers Improving the safety after using high alert medications. Eliminating wrong site, wrong client, wrong procedure surgery Improving the effectiveness of clinical alarm system & reducing risk of nosocomial e. JCAHO standard for Nursing practice: 15

Standards of care are the legal guidelines for nursing practice. The JCAHO requires that accredited hospitals have written nursing policies and procedures. The written policies and procedures of the employing institution detail how nurses are to perform their duties. These internal standards of care are quite specific and should be accessible on all nursing units. Eg. A policy / procedure outlining the steps that should be taken when changing a dressing or administering medication provides specific information about how nurses are to perform these tasks. The institutional policies and procedures must conform to state and federal laws, as well as community standards and cannot conflict with legal guidelines that define acceptable standards of care. The nurse is obligated to behave honestly and truthfully with regard to the client. REVIEW ORGANIZATION: Meaning: Through the professional standards review organizational. The government has established certain mechanisms to control cost under the common term utilization review. Organizational Design: Organizational designs in general determine how activities should be grouped within the organization and how decisions will be made. The focus here is mainly on the structural issues pertaining to organization design and organization performance. There are two types of organization structures Functional organization Divisional organization 1. Functional: Functional structures are common in general hospitals (private and public) department of surgery, medicine, nursing, medical records, etc. 16

2. Divisional: Divisional structures are common in large teaching hospitals; in many cases they have their own clinical and administrative support services. However, whatever may be the types of hospital structures two chains of command co-exist. One proceeds from superintendent of hospital down through all the support services and providers system of orders and of accountability from the top to bottom. On the other hands, hierarchy of the doctors stands completely outsides this structure. No person in the administrative hierarchy gives common to the medical staff members and though doctors do give commands to those in administrative hierarchy, they do it in almost unique way. UTILIZATION REVIEW: Introduction: The rapidly growing variety of available health care services and the number of providers have concern among groups regarding the quality of health care given. These groups include patient advocates, providers and the federal government. They are seeking methods of monitoring the care patients receive. The social security Act was amended to allow the formation of professional standards review organization to monitor both the quality and cost of health care services provided with government funds. Purposes of utilization review: Utilization review is to ensure and document that care is necessary and its provided at the appropriate level. The utilization review activities with which will come into contact involve prior authorization for elective hospitalization and concurrent review during hospitalization. Government Insurance program in utilization Review: Prior authorization:

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When a patient is to be admitted to a hospital for elective medical or surgical care, permission must be obtained in advance. A review co-coordinator or physician associated with the PSRO will based on the information provided, determine the necessity of hospitalization. It services can be safety provided in out patient setting, the request for hospitalization. Out patient cost much less than impatient care and therefore encouraged. Health maintenance organization: Utilization review is built in to the health maintenance organization concept from the perspective of centralized control. Many HMOs conduct patient care through a certain type of services be reviewed by utilization review organization prior to authorization being given to proceed with the planned treatment. Some insurance carriers are trying to educate patients regarding proper utilization by putting on emphasis on primary care physicians to direct patient care, referrals to specialists, hospitalization, and length of stay. Second opinion for elective surgery: Some insurance companies are requiring a second opinion, when elective surgery is recommended. Patient is seen by another surgeon selected by insurance company. If the surgeon disagree, company may not pay for the procedure or may request third opinion. The medical Assistants role in Utilization Review: Role in utilization review is to know the restrictions. Insurance restrictions for cost containment will vary from one area to another in government and private concentration of primary care. Each patient select or assigned a primary care physician who manages patients needs. Refers patients to specialists or for hospitalization as needed.

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 This helps monitor activity. Other services not paid without primary physician referral. Avoid unnecessary services or self referral by patient to specialists. Emphasis of care: Care through 4MUs stressed maintain and preventive care It is based on the principle, that patients should seek care before problem begin or require major care. Through early intervention care can be provided at a reduced cost.

Insurance companies: Employees pay a majority portion of the health premiums for the employees. Employers encourage insurance carriers to assist cost containment. Rules and regulations that apply in the area to be learnt and to be alert to the changes that take place. System of arrangement with employers to be made to ensure program changes announcement are shared with all employees. Necessary permissions: If advance permission is needed for certain referrals or hospitalizations to be obtained by filling a proper forms and notifying the appropriate agencies or facilities. Hospital reviewers: Hospital utilization review co ordinate works with physicians to see the patient does not stay in the hospital any longer than medically necessary. Filling claim forms:

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Claim forms for medical to be done to file claims to insurance carriers. It is easier and faster to older claim form through local supply houses than insurance carriers our forms. Summary: So far we have discussed about Nursing Audit definition, purpose, objective, types, professional standard, review organization and review utilization.

Bibliography: 1. Basavanthappa BT (2202) :Nursing administration I st edition, published by Jaypee Brothers, page no: 435-438. 2. khan Ali Akbar Mohammed (1999) Hospital management I st edition, published by S.B. Nangia A.P.H. Publishing corporation, New Delhi page no 201-213. 3. H. Nancy Holmes (2003) five keys to successful Nursing management I st edition, published by lippincott Williams & wilkins page No: 311-316. 4. Kozier Oliver Fundamentals of Nursing concepts process and practice, 4 th edition, page no: 235-340. 5. Zwmer A.J. Professional adjustment and ethics for nurses in India, I st edition, BI publication, page no: 132-149. 6. Morquis and Huston Leadership roles and management function in nursing 4th edition, published by lippincotts company, Page No: 438-444. 7. Eggers DC. A and Conway AM, (2002), front office skills for the medical assistant Ist edition mosbys publication, missioning, Page No: 372. 8. Feutz- Harder Sheryl A ( 1991) Ethics committees A Resource for patient care decision-making Jona. Vol-21 No.4 April-1991 page No: 9-11. 20

SEMINAR ON
NURSING AUDIT, PROFESSIONAL STANDARD, REVIEW ORGANIZATION AND UTILIZATION REVIEW

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Submitted to
Mrs. Tamizharasi M.Sc. (Nsg.) Associate professor VMACON, Salem.

Submitted by

Ramlakhan Mali M.Sc. (Nsg.) 2nd year VMACON, Salem.

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